Hip Preservation Surgery in Patients With Femoroacetabular Impingement Syndrome and Acetabular Dysplasia Improves Functional Measures and Pain Catastrophizing.

Background Chronic hip pain is a debilitating condition that severely reduces one's quality of life. Prior studies uncovered a link between hip pathologies and pain catastrophizing, anxiety, and depression. The purpose of this study was to investigate whether hip preservation surgery in patients with femoroacetabular impingement syndrome (FAIS) and acetabular dysplasia (AD) improves functional outcomes and pain catastrophizing. Methods Patients with FAIS and AD were requested to complete a hip questionnaire both preoperatively and postoperatively at a single academic center (University of Texas Southwestern Medical Center, Dallas, Texas, USA). Pain catastrophizing was evaluated using the pain catastrophizing scale, and pain level was assessed using the visual analog scale. Assessments of hip functional outcomes included the hip outcome score (HOS) and the hip disability and osteoarthritis outcome score (HOOS). Outcome measures before and after treatment were compared using the dependent samples t-test. A correlation analysis, using the Spearman partial correlation coefficient (rs), was conducted to evaluate the relationship between variables. Results The results indicated a clinically significant improvement in functional measures and pain catastrophizing in patients who underwent hip preservation surgery. The most significant discovery was an inverse relationship between both HOOS quality of life (rs=-0.293, p=0.0065, false discovery rate (FDR)=0.0210) and HOS activities of daily living (rs=-0.242, p=0.0254, FDR=0.0423) and pain catastrophizing; however, similar improvements were seen in pain catastrophizing with improvements in other functional outcomes. Conclusion Undergoing hip preservation surgery for patients with AD or FAIS improved their hip functional measures and decreased pain catastrophizing postoperatively. The improvement of hip function, quality of life, and pain catastrophizing reveals an intricate link between the functional outcomes of hip preservation surgery and pain catastrophizing.

Deep learning generated lower extremity radiographic measurements are adequate for quick assessment of knee angular alignment and leg length determination.

PURPOSE: Angular and longitudinal deformities of leg alignment create excessive stresses across joints, leading to pain and impaired function. Multiple measurements are used to assess these deformities on anteroposterior (AP) full-length radiographs. An artificial intelligence (AI) software automatically locates anatomical landmarks on AP full-length radiographs and performs 13 measurements to assess knee angular alignment and leg length. The primary aim of this study was to evaluate the agreements in LLD and knee alignment measurements between an AI software and two board-certified radiologists in patients without metal implants. The secondary aim was to assess time savings achieved by AI. METHODS: The measurements assessed in the study were hip-knee-angle (HKA), anatomical-tibiofemoral angle (aTFA), anatomical-mechanical-axis angle (AMA), joint-line-convergence angle (JLCA), mechanical-lateral-proximal-femur-angle (mLPFA), mechanical-lateral-distal-femur-angle (mLDFA), mechanical-medial-proximal-tibia-angle (mMPTA), mechanical-lateral-distal-tibia- angle (mLDTA), femur length, tibia length, full leg length, leg length discrepancy (LLD), and mechanical axis deviation (MAD). These measurements were performed by two radiologists and the AI software on 164 legs. Intraclass-correlation-coefficients (ICC) and Bland-Altman analyses were used to assess the AI's performance. RESULTS: The AI software set incorrect landmarks for 11/164 legs. Excluding these cases, ICCs between the software and radiologists were excellent for 12/13 variables (11/13 with outliers included), and the AI software met performance targets for 11/13 variables (9/13 with outliers included). The mean reading time for the AI algorithm and two readers, respectively, was 38.3, 435.0, and 625.0 s. CONCLUSION: This study demonstrated that, with few exceptions, this AI-based software reliably generated measurements for most variables in the study and provided substantial time savings.

The Relationship Between Postoperative Patient-Reported Psychological Outcomes and Preoperative Pain Characteristics in Patients Who Underwent Periacetabular Osteotomy.

This study sought to investigate the relationship between multiple preoperative characteristics of pain (maximum pain severity location, the presence of pain in certain locations, the highest level of pain, and the number of pain locations) and psychological outcome measures as reported by patients. Fifty-four hips (50 patients) that underwent periacetabular osteotomy to treat acetabular dysplasia between February 2017 and July 2020 were reviewed using the Depression, Anxiety, and Stress Scale-21 (DASS21), Hospital Anxiety and Depression Scale (HADS), and Pain Catastrophizing Scale (PCS), radiographic analysis, and questionnaires concerning pain severity/location. Twenty-six hips had their worst pain in the groin, whereas 28 hips had greater or equal levels of pain at another location. There was no significant difference between these two locations on any of the postoperative psychological outcomes (HADS, P=.53; DASS21, P=.85; PCS, P=.97). Additionally, there was not a significant relationship between pain in any location other than the groin and any postoperative psychological outcomes (P≥.08). Finally, the highest level of preoperative pain and the number of locations of pain demonstrated no significant relationship with postoperative psychological outcomes (maximum severity: HADS, P=.28; DASS21, P=.49; PCS, P=.57; number of pain locations: HADS, P=.47; DASS21, P=.60; PCS, P=.35). Variance in preoperative pain location, severity, and number of pain locations seemingly does not result in any significant effect on postoperative psychological outcomes. Thus, a large range of patients with acetabular dysplasia may experience similar, favorable psychological outcomes from treatment with periacetabular osteotomy notwithstanding the characteristics of preoperative pain. [Orthopedics. 2024;47(1):28-33.].

Three-Dimensional CT and 3D MRI of Hip- Important Aids to Hip Preservation Surgery.

Common hip internal derangements include femoroacetabular impingement (FAI), developmental dysplasia of hip (DDH) dysplasia, and avascular necrosis (AVN) of the femoral head. These are initially screened by radiographs. For preoperative planning of hip preservation, 3-dimensional (3D) CT is commonly performed to assess bony anatomy and its alterations. Magnetic resonance imaging (MRI) is used to evaluate labrum, hyaline cartilage, tendons, synovium, and loose bodies, and provides vital information for surgical decision-making. However, conventional 2D MRI techniques are limited by lack of isotropic multiplanar reconstructions and partial volume artifacts. With advancements in hardware and software, novel isotropic 3D MR Proton Density images are acquired with acceptable acquisition times leading to improved visualization of soft tissue and osseous structures for various hip conditions. Three-Dimensional MRI allows multiplanar non-gap reconstructions along the structures of interest. It results in detection of small, otherwise inconspicuous labral tears without the need for MR arthrogram, which can be subsequently measured. In addition, radial reconstructions of the femoral head can be performed from original 3D volume MR imaging and CT imaging without the need for individual different plane acquisitions. Three-Dimensional MRI thus impacts surgical decision-making for the important common hip derangement conditions. For example, femoral head hyaline cartilage loss may make hip preservation difficult or impossible. In this review, we discuss the advantages and technical details of 3D CT and MRI and their significant role in aiding hip preservation surgery for common hip conditions. The conditions discussed in this article include FAI, DDH, AVN, synovial disorders, cartilaginous tumors, and hip fractures.

Duration of Symptoms Does Not Significantly Influence Short-term Outcomes for Patients Undergoing Periacetabular Osteotomy.

Factors influencing the clinical outcomes after periacetabular osteotomy (PAO) have not been well explored. This study evaluated the influence of symptom duration in developmental dysplasia of the hip on short-term patient-reported outcomes after PAO. A retrospective review of prospectively collected data identified PAOs performed on 139 patients. Sixty-five patients were then stratified into two groups based on preoperative symptom duration: 2 years or less (n=22) vs more than 2 years (n=43). We compared the results of hip-specific patient-reported outcome surveys collected preoperatively and postoperatively. When comparing the two groups, we found no significant differences in clinical outcome scores except for the UCLA Activity Scale. The shorter duration group achieved improvement 6 months postoperatively on the visual analog scale average pain score (from 4.5 to 2.167; P=.0017), International Hip Outcome Tool-12 (from 42.95 to 59.19; P=.0176), and Harris Hip Score (from 53.88 to 69.88; P=.049). The longer duration group also achieved postoperative improvement across multiple surveys. Nevertheless, a multivariate analysis controlling for age, sex, and body mass index and found that symptom duration did not independently affect the change in clinical outcomes. Although PAO leads to improvements in functional status and pain, preoperative symptom duration does not significantly affect these clinical outcomes. [Orthopedics. 2023;46(6):365-372.].

The relationship between patient-reported outcomes and preoperative pain characteristics in patients who underwent total hip arthroplasty.

AIMS: This study aims to answer the following questions in patients with hip osteoarthritis (OA) who underwent total hip arthroplasty (THA): are patient-reported outcome measures (PROMs) affected by the location of the maximum severity of pain?; are PROMs affected by the presence of non-groin pain?; are PROMs affected by the severity of pain?; and are PROMs affected by the number of pain locations? METHODS: We reviewed 336 hips (305 patients) treated with THA for hip OA from December 2016 to November 2019 using pain location/severity questionnaires, modified Harris Hip Score (mHHS), Hip Outcome Score (HOS), international Hip Outcome Tool (iHOT-12) score, and radiological analysis. Descriptive statistics, analysis of covariance (ANCOVA), and Spearman partial correlation coefficients were used. RESULTS: There was a significant difference in iHOT-12 scores between groups experiencing the most severe pain in the groin and the trochanter (p = 0.039). Additionally, more favourable mHHS scores were related to the presence of preoperative pain in trochanter (p = 0.049), lower back (p = 0.056), lateral thigh (p = 0.034), and posterior thigh (p = 0.005). Finally, the maximum severity of preoperative pain and number of pain locations had no significant relationship with PROMs (maximum severity: HHS: p = 0.928, HOS: p = 0.163, iHOT-12 p = 0.233; number of pain locations: HHS: p = 0.211; HOS: p = 0.801; iHOT-12: p = 0.112). CONCLUSION: Although there was a significant difference in iHOT-12 scores between patients with the most severe pain in the groin or trochanter, and the presence of pain in the trochanter, lower back, lateral thigh, or posterior thigh was related to higher mHHS scores, the majority of preoperative pain characteristics did not have a significant impact on outcomes. Therefore, a broad array of patients with hip OA might expect similar, favourable outcomes from THA notwithstanding preoperative pain characteristics. Cite this article: Bone Jt Open 2022;3(4):332-339.

Does Preoperative Activity Level Affect Postoperative Outcomes Following Total Hip Arthroplasty?

BACKGROUND: Many patients electing to undergo total hip arthroplasty (THA) value continuing active lifestyles when considering treatment options. Addressing these concerns requires evaluating the effect of preoperative activity level on patient-reported outcomes and improvement following THA. METHODS: Three hundred thirty-five patients (368 hips) who underwent THA with a minimum 6-month (mean 533 ± 271 days) follow-up completed preoperative and postoperative University of California, Los Angeles (UCLA) activity score along with various patient-reported measures of function, pain, and mental state. Preoperative UCLA score divided patients into inactive, mild, and active groups. Analysis of covariance controlling for age, sex, body mass index, surgical approach, implant, bilateral cases, conversions, and follow-up time evaluated differences among groups for postoperative outcomes with subsequent Tukey-Kramer pairwise comparisons. RESULTS: Mildly active patients (73:139 male:female) had better postoperative outcomes than inactive patients (40:70 male:female) for UCLA score, EuroQol Visual Analog Scale (EQVAS), Hip Outcome Score (HOS), 12-item Short-Form (SF-12) Physical, and Visual Analog Pain Scale (average/now/worst) (P values <0.001/<0.001/<0.001/<0.001/0.003/<0.001/<0.001). Active patients (32:14 male:female) had better postoperative outcomes than inactive patients for UCLA score, EQVAS, HOS, SF-12 Physical, and Visual Analog Pain Scale Worst (P values <0.001/0.024/0.001/0.001/0.017). No postoperative outcome differences existed between active and mild patients. Inactive patients displayed greater outcome improvements than mildly active patients for UCLA score, Harris Hip Score, and International Hip Outcome Tool (P values <0.001/<0.001/0.013) and active patients for UCLA score, EQVAS, HOS, International Hip Outcome Tool, and SF-12 Physical (P values <0.001/0.008/0.013/0.022/0.004). CONCLUSIONS: Inactive patients achieve greater measure improvements following THA. Active patients achieve better absolute outcomes than inactive patients; however, increasing activity levels do not incrementally improve patient-reported outcome measures. Patients similarly improve pain and mental health regardless of activity level.

Correlation of the Imaging Features of Femoroacetabular Impingement Syndrome With Clinical Findings and Patient Functional Scores.

The relationship among the severity of the imaging features of femoroacetabular impingement syndrome (FAIS), patient symptoms, and function has not been elucidated. Understanding this relationship helps to improve the prognostic value of imaging. The goal of this study was to examine the correlation of clinical findings, patient pain, and function with severity, as measured with radiographic and 3-dimensional magnetic resonance imaging (3D-MRI). Data collected prospectively through a longitudinally maintained hip database were reviewed, and 37 hips from 31 patients were included. All patients were examined by an experienced orthopedic surgeon, and preoperative radiographs and 3D-MRI were obtained. Preoperatively, the patients completed validated patient-reported outcome measures (PROMs). Mean±SD alpha angles were 69.4°±10.3°, 70.0°±10.3°, 70.6°±8.4°, and 74.8°±9.2° at 12 o'clock, 1 o'clock, 2 o'clock, and 3 o'clock, respectively. Mean lateral center edge angle was 30.1°±5.3°. The authors did not observe a statistically significant correlation between PROMs and the features measured by radiographs and 3D-MRI (P>.05). In this subset of prospectively imaged patients with FAIS, the authors did not find a correlation between the severity of symptoms measured by PROMs and features on radiographs and 3D-MRI. The severity of dysfunction is multifactorial, and anatomic severity, as measured radiographically and with 3D-MRI, may not correlate with symptoms. Further investigation is necessary to address the sources of patient pain. [Orthopedics. 2021;44(4):e577-e582.].

Arthroscopic Capsular Management of the Hip: A Comparison of Indications for and Clinical Outcomes of Periportal Versus Interportal Capsulotomy.

PURPOSE: To compare the clinical outcomes of periportal capsulotomy versus interportal capsulotomy with closure using a standard clinical algorithm at a minimum of 2 years after hip arthroscopy. METHODS: A retrospective cohort study of patients treated from July 2015 to October 2017 was conducted to determine the effects of 2 capsular management approaches on clinical outcomes. When patient pathology limited adequate exposure via periportal capsulotomy, an interportal capsulotomy was performed. The capsular management approaches were correlated with the following patient-reported outcomes (PROs) at 2 years: Hip Outcome Score (HOS), 12-item International Hip Outcome Tool, visual analog scale for pain, and patient satisfaction. Preoperative comparisons between the 2 groups were analyzed using t tests or the Fisher exact test, depending on the category of data. Two-tailed independent t tests were performed to evaluate whether preoperative and follow-up outcome scores were significantly different between patients treated with a periportal capsulotomy and those treated with an interportal capsulotomy. RESULTS: Overall, patients in both groups experienced significant improvements in all PROs on postoperative comparisons at 2-year follow-up (P < .001). The mean changes in the PROs were as follows: HOS-Activities of Daily Living, 24.7 in the periportal group and 23.5 in the interportal group (P = .484); HOS-Sport-Specific Subscale, 30.2 and 31.3, respectively (P = .895); 12-item International Hip Outcome Tool score, 41.9 and 40.2, respectively (P = .564); and visual analog scale pain score, -40.9 mm and -34.5 mm, respectively (P = .791). Additionally, no statistically significant difference in patient satisfaction at 2-year follow-up was found between patients who underwent interportal capsulotomy and those who underwent periportal capsulotomy (P = .604). CONCLUSIONS: At 2-year follow-up, patients who underwent a periportal capsulotomy reported statistically and clinically significant improvements in PROs and satisfaction with the surgical intervention. This study confirms that the use of a simple clinical algorithm for selection of periportal capsulotomy or interportal capsulotomy with closure results in acceptable management decisions as defined by 2-year PROs. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

A Case Report of a 44-Year-Old Woman With Camurati-Englemann Disease: A Case Report.

CASE: A 44-year-old woman presented with easy fatigability, diplopia, dizziness, and a 2-year history of pelvic, hip, and lower extremity aching and pain. Radiograph, magnetic resonance imaging, computed tomography, and histopathologic imaging studies were obtained. Hypersclerosis of the affected bones led to the initiation of a sclerotic bone dysplasia workup and sequencing of the transforming growth factor beta 1 gene located on chromosome 19q13 revealed a heterozygous rare missense variant in exon-4, leading to a final diagnosis of Camurati-Engelmann disease (CED). Medical treatment thus far has had a minimal effect on her symptoms, and the patient continues to be followed. CONCLUSIONS: This specific mutation has been reported only once previously in a patient with CED. This case report expands the typical phenotype associated with CED in association with the c.667T>C, p.Cys223Arg variant.

Depression and Non-modifiable Patient Factors Associated with Patient Satisfaction in an Academic Orthopaedic Outpatient Clinic: Is it More Than a Provider Issue?

BACKGROUND: Patient satisfaction surveys play an increasingly important role in United States healthcare policy and serve as a marker of provided physician services. In attempts to improve the patient's clinical experience, focus is often placed on components of the healthcare system such as provider interaction and other experiential factors. Patient factors are often written off as "non-modifiable"; however, by identifying and understanding these risk factors for dissatisfaction, another area for improvement and intervention becomes available. QUESTIONS/PURPOSES: (1) Do patients in the orthopaedic clinic with a preexisting diagnosis of depression report lower satisfaction scores than those without a preexisting diagnosis of depression? (2) What other non-modifiable patient factors influence patient-reported satisfaction? METHODS: We reviewed Press Ganey Survey scores, which assess patient experiential satisfaction with a single clinical encounter, from 3044 clinic visits (2527 patients) in adult reconstructive, sports, and general orthopaedic clinics at a single academic medical center between November 2010 and May 2017, during which time approximately 19,000 encounters occurred. Multiple patient factors including patient age, gender, race, health insurance status, number of previous clinic visits with their physician, BMI, and a diagnosis of depression were recorded. Patient satisfaction was operationalized as a binary outcome as satisfied or less satisfied, and a multiple logistic regression analysis was used to estimate the odds of being satisfied. RESULTS: After adjusting for all other covariates in the model, we found that patients with a diagnosis of depression were less likely to be satisfied than patients without this diagnosis (odds ratio 0.749 [95% confidence interval, 0.600-0.940]; p = 0.01). Medicare-insured patients were more likely to be satisfied than non-Medicare patients (OR 1.257 [95% CI, 1.020-1.549]; p = 0.03), patients in the sports medicine clinic were more likely to be satisfied than those seen in the general orthopaedic clinic (OR 1.397 [95% CI, 1.096-1.775]; p = 0.007), and established patients were more likely to be satisfied than new patients (OR 0.763 [95% CI, 0.646-0.902]; p = 0.002). CONCLUSIONS: Given the association of depression with lower satisfaction with a single visit at the orthopaedic clinic, providers should screen for depression and address the issue during the outpatient encounter. The impact of such comprehensive care or subsequent treatment of depression on improving patient-reported satisfaction offers areas of future study. LEVEL OF EVIDENCE: Level III, therapeutic study.

Treatment of intra-articular hip malignancy with extra-articular resection, preservation of the acetabular columns, and total hip arthroplasty.

Intra-articular malignant lesions of the hip present significant challenges. Resection often requires large resection of the acetabular bone and pelvic columns. Concurrent reconstruction options after intra-articular hip tumors are challenging and may necessitate the use of techniques and implants with uncertain long-term survivorship. We present a case of an intra-articular hip malignancy with extra-articular resection and preservation of the acetabular columns with reconstruction using a cementless acetabular shell fixed with screws.

3D CT segmentation of CAM type femoroacetabular impingement-reliability and relationship of CAM lesion with anthropomorphic features.

OBJECTIVE:: Evaluate feasibility and reliability of 3DCT semi-automatic segmentation and volumetrics of CAM lesions in femoroacetabular impingement and determine correlations with anthropometrics. METHODS:: A consecutive series of 43 patients with CAM type FAI underwent 3DCT. 20 males and 23 females (30 unilateral and 13 bilateral symptomatic hips) were included. 56 CAM lesions and femoral heads were segmented by two readers. Radial images were obtained for alpha angles. Pearson and ICC correlations were used for analysis. RESULTS:: In 43 patients (male: female = 1 : 1.15), mean ± SD of age, height, BMI were 36.6 ± 11.47 years, 1.72 ± 0.10 meters and 26.25 ± 4.31 kg m-². Femoral head and bumps were segmented in 4 min. Inter reader reliability was good to excellent for volumetrics and poor for alpha angles. Mean ± SD of CAM lesion and femoral head volumes were significantly larger (6.7 ± 2.5 cc3 and 62.9 ± 10.8 cc3) for males than females (p < 0.001) and these increased with increasing patient height (Pearson correlation and p-values = 0.45, 0.0006; 0.82, < 0.0001 respectively). CONCLUSION:: Volumetric analysis of CAM lesion shows better inter reader reliability than alpha angle measurements. CAM and femoral head volumes exhibit significant positive correlations with patient heights and male gender that may aid in pre-operative planning for femoroplasty. ADVANCES IN KNOWLEDGE:: Femoral head & CAM volumes are segmented three times faster than alpha angles with superior inter reader reliability than alpha angles. Femoral head & CAM volumes are significantly larger in males and positively correlate with patients' heights.

Does 3DMR provide equivalent information as 3DCT for the pre-operative evaluation of adult Hip pain conditions of femoroacetabular impingement and Hip dysplasia?

OBJECTIVE:: Femoroacetabular impingement (FAI) and hip dysplasia (HD) are frequently evaluated by isotropic CT (3DCT) for preoperative planning at the expense of radiation. The aim was to determine if isotropic MRI (3DMR) imaging can provide similar quantitative and qualitative morphological information as 3DCT. METHODS:: 25 consecutive patients with a final diagnosis of FAI or HD were retrospectively selected from December 2016-December 2017. Two readers (R1, R2) performed quantitative angular measurements on 3DCT and 3DMR, blinded to the diagnosis and each other's measurements. 3DMR and 3DCT of the hips were qualitatively and independently evaluated by a radiologist (R3), surgeon (R4), and fellow (R5). Interobserver and intermodality comparisons were performed. RESULTS:: The ICC was good to excellent for all measurements between R1 and R2 (ICC:0.60-0.98) and the majority of intermodality measurements for R1 and R2. Average inter-reader and inter-modality PABAK showed good to excellent agreement for qualitative reads. On CT, all alpha angles (AA) were significantly lower in dysplasia patients than in cam patients (p < 0.05). All lateral center-edge angle (LCEA) were significantly lower in dysplasia than in cam patients (p < 0.05). On MR, AA at 12, 1, and 2 o'clock, and LCEA at center were significantly lower in dysplasia patients than in cam patients (p < 0.05). CONCLUSION:: 3DMR offers similar qualitative and quantitative analysis as 3DCT in adult painful hip conditions. ADVANCES IN KNOWLEDGE:: 3DMR has good potential to replace 3DCT and serve as a one-stop modality for bone and soft tissue characterizations in the pre-operative evaluation of FAI and HD.

Damage control resuscitation in combination with damage control laparotomy: a survival advantage.

BACKGROUND: Damage control laparotomy (DCL) improves outcomes when used in patients with severe hemorrhage. Correction of coagulopathy with close ratio resuscitation while limiting crystalloid forms a new methodology known as damage control resuscitation (DCR). We hypothesize a survival advantage in DCL patients managed with DCR when compared with DCL patients managed with conventional resuscitation efforts (CRE). METHODS: This study is a 4-year retrospective study of all DCL patients who required >or=10 units of packed red blood cells (PRBC) during surgery. A 2-year period after institution of DCR (DCL and DCR) was compared with the preceding 2 years (DCL and CRE). Univariate analysis of continuous data was done with Student's t test followed by multiple logistic regression. RESULTS: One Hundred twenty-four and 72 patients were managed during the DCL and CRE and DCL and DCR time periods, respectively. Baseline patient characteristics of age, Injury Severity Score, % penetrating, blood pressure, hemoglobin, base deficit, and INR were similar between groups. There was no difference in quantity of intraoperative PRBC utilization between DCL and CRE and DCL and DCR study periods: 21.7 units versus 25.5 units (p = 0.53); however, when compared with DCL and CRE group, patients in the DCL and DCR group received less intraoperative crystalloids, 4.7 L versus 14.2 L (p = 0.009); more fresh frozen plasma (FFP), 18.2 versus 6.4 (p = 0.002); a closer FFP to PRBC ratio, 1 to 1.2 versus 1 to 4.2 (p = 0.002); platelets to PRBC ratio, 1:2.3 versus 1:5.9 (0.002); shorter mean trauma intensive care unit length of stay, 11 days versus 20 days (p = 0.01); and greater 30-day survival, 73.6% versus 54.8% (p < 0.009). The addition of DCR to DCL conveyed a survival benefit (odds ratio; 95% confidence interval: 0.19 (0.05-0.33), p = 0.005). CONCLUSION: This is the first civilian study that analyses the impact of DCR in patients managed with DCL. During the DCL and DCR study period more PRBC, FFP, and platelets with less crystalloid solution was used intraoperatively. DCL and DCR were associated with a survival advantage and shorter trauma intensive care unit length of stay in patients with severe hemorrhage when compared with DCL and CRE.